an 85 year old male resident of an extended care facility reaches for the hand of the unlicensed assistive personnel uap and tries to kiss her hand se
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Nursing Elites

ATI LPN

ATI PN Adult Medical Surgical 2019

1. An 85-year-old male resident of an extended care facility reaches for the hand of an unlicensed assistive personnel (UAP) and tries to kiss her hand several times during his morning care. The UAP reports the incident to the charge nurse. What is the best assessment of the situation?

Correct answer: C

Rationale: In this scenario, the resident's actions of reaching for the UAP's hand and trying to kiss it could indicate a need for touch rather than intentional sexual harassment. The best assessment is to consider the possibility that the client may be experiencing touch deprivation and is seeking appropriate ways to express his need for physical contact. Providing guidance on acceptable ways to seek physical affection can help address the underlying issue and improve the resident's interactions with the staff. Choice A is incorrect because assuming sexual harassment without understanding the context and potential reasons behind the behavior can lead to misinterpretation. Choice B is inappropriate as reassignment based on gender is not a solution and does not address the root cause of the behavior. Choice D is not the best approach as it focuses solely on setting boundaries without considering the resident's underlying need for touch.

2. A client with hypothyroidism is started on levothyroxine (Synthroid). Which statement by the client indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D. Levothyroxine is typically a lifelong therapy for hypothyroidism. It should not be discontinued even if symptoms improve because the medication helps replace the deficient thyroid hormone. Stopping the medication prematurely can lead to a recurrence of symptoms and potential complications. Patients must understand the importance of continuous levothyroxine therapy and the necessity of regular follow-up with their healthcare provider to monitor thyroid levels and adjust the dosage as needed.

3. While assessing a client with preeclampsia who is receiving magnesium sulfate, the nurse notes her deep tendon reflexes are 1+, respiratory rate is 12 breaths/minute, urinary output is 90 ml in 4 hours, and magnesium sulfate level is 9 mg/dl. What intervention should the nurse implement based on these findings?

Correct answer: C

Rationale: The nurse should stop the magnesium sulfate infusion immediately in a client with preeclampsia exhibiting diminished reflexes, respiratory depression, and low urinary output, which indicate magnesium sulfate toxicity. This action is crucial to prevent further complications and adverse effects on the client.

4. A client is admitted with a diagnosis of acute pancreatitis. Which laboratory value should the nurse monitor closely?

Correct answer: A

Rationale: In acute pancreatitis, serum amylase is a crucial laboratory value to monitor closely. Elevated levels of serum amylase are a key indicator of pancreatic inflammation and can help confirm the diagnosis of acute pancreatitis. Therefore, monitoring serum amylase levels is essential for assessing the progression and severity of the condition in a client with acute pancreatitis.

5. The preceptor is orienting a new graduate nurse to the critical care unit. The preceptor asks the new graduate to state symptoms that most likely indicate the beginning of a shock state in a critically ill client. What findings should the new graduate nurse identify?

Correct answer: D

Rationale: Tachycardia, mental status change, and low urine output are early indicators of shock. In a critically ill client, these findings suggest a decrease in tissue perfusion. Prompt recognition and intervention are crucial to prevent the progression of shock and its complications.

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